Reflections on Schizophrenia: Sources of the Social Stigma in Japan

REFLECTIONS ON SCHIZOPHRENIA:SOURCES OF THE SOCIAL STIGMA IN JAPAN Jerome Young & Yutaka Ono Originally published in Psychiatric Networks, vol. 3, no. 2, 2000 (pp. 41-52)ABSTRACT In this paper we consider the sources of the social stigma associated with schizophrenia in Japan. We begin by arguing that any conception of schizophrenia is tied to a conception of self (something implicit in clinical conceptions of die disorder) and that this conception will have subtle cultural differences. We point out how the Japanese expression currently used to translate the Western diagnostic term contributes to the stigma associated with this disorder because of an implicit view of the self contained in the translation. Next, since delusions are central to schizophrenia, we offer a critique of the conventional clinical definition of delusion and argue that it is conceptually weak. We argue that what bothers most people about someone who is schizophrenic is not that he has false beliefs per se, but what he does while experiencing a delusional state. It is as agents in the world relating to others that schizophrenics present problems for themselves, their family members, state authorities and clinicians and why they have been so highly stigmatized socially. Since families in Japan have tended to play a major role in the care of family members with schizophrenia, a patient's bizarre actions cause family members to experience shame and guilt and lead to manifold social problems for the patient. Finally, we discuss the increasingly important role biochemistry plays in the treatment of schizophrenics in Japan and argue that the wider use of neuroleptics, along with a greater understanding by family members of both the psychosocial and biochemical nature of schizophrenia, will probably lead to a lessening of the stigma associated with this disorder. Key Words: Schizophrenia, stigma, self, delusion, agency, biochemistryI. INTRODUCTION The idea of schizophrenia was imported into Japan originally through the work of Kraepelin (1896) and the source of the negative image associated with this disorder can probably be traced back to his work. He introduced the idea that there are two classes of major psychoses; namely, manic-depressive psychosis and dementia praecox, the latter being the historical predecessor of the term "schizophrenia." He thought that dementia praecox was a chronic, or progressive, brain disease which causes patients to experience severe impairment in their cognitive functioning. Bleuler (1911) criticized this pessimistic viewpoint and instead focused on the splitting nature of this disorder and named it schizophrenia. That a diagnosis of schizophrenia can have a stigmatizing effect on both the patient and family is certainly a problem in the West (Szasz 1961; Barham 1993), but the stigmatization of mental illness in Japan and other Asian countries is perhaps a bigger problem because mental illness in general is more highly stigmatized here than in the West (Hinton and Kleinman 1993). Schizophrenia as an illness is particularly a problem in Japan and a diagnosis of this mental illness produces a fear analogous to that of a diagnosis of cancer in physical medicine (Munakata 1986). As was revealed in the well-known US/UK Diagnostic Project (Cooper et al. 1972), local tradition has an influence on the diagnosis of schizophrenia. More than this, however, local tradition has an influence on how the disorder is perceived and understood socially because underlying the theory of schizophrenia itself is a theory about the self (Margolis 1991). Because cultural norms, habits, practices, interests and so on inevitably form a particular society's ideas of what constitutes normality, any conception of self will be localized and these localized conceptions of self will also influence how schizophrenia is understood. Since schizophrenia is frequently construed in the medical model in terms of reality testing (DSM-III-R 1987), whatever theory we have about the nature of schizophrenia will tell us a great deal about our theory of man's relationship to the world because the self identifies reality (Marsella 1982). The consequences of this localization can be seen linguistically by looking at the Japanese translation of this Western diagnostic category. By carefully analyzing the Japanese term we can begin to acquire a sense of the localized, culturally-specific conception of self found in Japanese society and can begin to understand why this diagnostic label contributes to stigmatizing schizophrenia as an illness in Japan. We can begin to appreciate more fully why schizophrenia as an illness is so highly stigmatized by considering the schizophrenic as an agent As an agent, a person with schizophrenia is motivated to act, just as anyone else, according to his beliefs, desire, wishes, wants and so on, but he runs into problems because his motives, or reasons for acting, are distorted by the illness and lead to manifold social problems for the patient, his family and those around him and, consequently, lead to him to being singled out socially. In a clinical setting, a schizophrenic person's thoughts are closely examined and a clinical judgment of delusion, or cognitive deficit, is pronounced; however, the person's actions and the reasons (delusional though they may be) used to justify them are what brought the person to the attention of medical professionals in the first place. Therefore, to reduce delusional experience to a dysfunction of reason (pure reason, if you will) gives only a partial picture of the schizophrenic's experience of the illness and says nothing when it comes to the psychotic's status as an agent in society. This is an unfortunate omission for it is what the schizophrenic does that is so disturbing to those around him. Any purely cognitive definition of delusion (i.e., reducing delusion to false belief) places significant limitations on our understanding of the schizophrenic person's experience, both psychologically and socially, as well as places unnecessary limitations on our ability to understand one of the chief sources of the social stigmas associated with schizophrenia. Steps clearly need to be taken to overcome the stigma associated with schizophrenia in Japan. One promising avenue is the introduction of newer atypical anti-psychotic agents in the treatment of the disorder. These drugs seem to be as effective as the traditional anti-psychotic drugs, produce fewer extra-pyramidal side-effects, and seem to be effective in treating patients who don't respond to the typical drug therapies. Once patients begin to understand that schizophrenia is a biochemically-based disorder, that it can be treated effectively using drug therapy, that the illness is not necessarily a life sentence of suffering, they will be better able to accept and benefit from treatment. Another promising avenue, one which would enhance drug therapy, is the new psychosocial therapies involving both family intervention and cognitive behavior therapy (International Congress of Cognitive Psychotherapy 2000). The "Verona Program" (Burti, ICCP 2000) and the "Optimal Treatment Project" (Falloon, ICCP 2000) have shown promise in helping to ameliorate the persistent psychotic symptoms of schizophrenia and, perhaps more importantly, in helping people with schizophrenia to live more productive lives. Schizophrenics in Japan could benefit from a more integrated approach to treatment because patients and their family members would understand the nature of the illness better and would not, therefore, be prone to experience the feelings of guilt or shame which are currently inevitable by-products of such a diagnosis in Japan.II. THE CONCEPT OF SELF AND SCHIZOPHRENIA In Japan, families feel great distress when one of their members is diagnosed as being psychotic because it is perceived as reflecting poorly on the family itself (Asai 1983). Part of this feeling is probably due to the lingering influence in popular culture of Kraepelin's pessimistic view of this illness. However, feelings of guilt and shame are also probably the result of the way schizophrenia has been translated into Japanese. Schizophrenia was translated as seishin-bunretsu-byou. What we find is that these Chinese characters (Kanji) paint a highly disturbing picture of the self, one which runs counter to cultural norms about what constitutes normality for selves In Japan. A careful analysis of the Kanji will reveal why a diagnosis of schizophrenia is so dreadful and why the term itself strengthens the social stigma associated with the disorder. In Japanese, the term "seishin-bunretsu-byou" has many subtle linguistic connotations. Seishin connotes "mind", "spirit" or "soul"; Bunretsu means "splitting", "disorganization", or "fragmentation"; and, Byou means "disease", "sickness" or "illness". The sense that one gets from these Kanji, then, is that this sickness is a splitting of the mind; this is, no doubt, the original translator's goal in rendering Bleuler's (1911) term into Japanese. Although the translator may have tried to adhere closely to Bleuler's term, in fact, the connotations in the Japanese expression are misleading. Seishin-bunretsu-byou means more to your average Japanese than just the splitting of the mind; it also implies an illness or disease in which there is a disorganization, or fragmentation, of the soul or spirit. Clearly, the implications of these Kanji go far beyond the clinical understanding of this disorder. The culturally specific connotations of the Japanese term therefore make a diagnosis of seishin-bunretsu-byou culturally problematic. The Japanese conceive of the self as a harmonious, simple, natural whole (Lebra 1976). While in the West there is a philosophical tradition of separating the mind and body, in Japan they are thought to be indivisible (Lock 1987). For the Japanese, then, a healthy person is one whose mind and body are in harmony, are balanced. The implicit conception of self contained in the term, therefore, has devastating consequences for the patient and his family and their attitude to this disorder. Since families in Japan piay a much more significant role in the treatment of ill family members than in the West (Lin et al., 1991), the burden placed on them for the care of an ill family member is great. Hence, being faced with a loved one with this disorder causes families to feel some guilt (tsumi no ishiki) because they may feel personally responsible for their loved one's illness. Furthermore, they may also experience some feelings of public shame (haji) because they have and are caring for a family member with an "incurable" illness. The linguistic nuances of this term, therefore, serve only to amplify the stigmatized impression of this disorder that already exists in popular culture. It should be noted that this observation about the negative connotations of the Kanji for schizophrenia goes beyond the borders of Japan. Since Kanji are used in China and Korea as well, a large portion of the world's population would have similar misleading negative impressions of this disorder. The negative linguistic connotations in the Japanese term also effects the treatment of the disorder. Because our view of schizophrenia is still strongly influenced by Western models of this illness (particularly, Kraepelin's concept), we still tend to think that schizophrenia is a disease in which the patient progressively deteriorates, despite the fact that the development of new treatment approaches, such as the use of neuroleptic agents (Koishikawa et ai. 1997) and cognitive behavior therapy (Leff, ICCP 2000), have had a favorable impact on the prognosis of this disorder. The Japanese term, therefore, amplifies the prognostic stigma that all schizophrenic patients are deteriorating and, hence, are unlikely to recover from their illness because it implies that their souls are fragmenting. Because the term perpetuates the stigma associated with this illness, it is more difficult for clinicians, patients, and relatives to discuss the disorder naturally and realistically. In fact, the negative impression amplified by the term distresses the individuals to such an extent that they hear very little of what is said to them by their clinician. The clinician, as a consequence, finds it difficult to build a collaborative relationship. Because of the negative connotations of these Kanji, psychiatrists in Japan have been reluctant to tell their patients when they suspect a diagnosis of schizophrenia. These negative connotation certainly give grounds for thinking that Munakata's (1986) belief that in Japan disguised diagnoses are given because of social stigmas associated with certain illnesses is justified. It appears, then, that mental health professionals are sensitive to the potentially harmful connotations of these Kanji. Given the clinical importance of sharing information of a disorder with the patients and their families, it is disadvantageous to clinical practice in Japan to use a term with which patients are uncomfortable, one which might cause both patients and families unreasonable suffering. If the use of the term Seishin-bunretsu-byou is detrimental to a patient's treatment and attitude toward the illness, it would be better not to use the term at all. Actually, the National Federation of Families of the Mentally III in Japan proposed changing the term to a less stigmatized one in order to minimize the detrimental effects of this term. Currently, the Committee on the Concepts and Terminology of Psychiatric Disorders of the Japanese Society of Psychiatry and Neurology is investigating the problems associated with the term and is discussing the pros and cons of changing the name (Ono et al. 1999).

III. CRITIQUE OF THE CLINICAL DEFINITION OF DELUSION As Jaspers (1963) said many years ago, the basic characteristic of madness is delusion; still today, delusion is crucial as one of the chief (i.e., first-rank) symptoms of schizophrenia. The conventional clinical definition, however, is problematic because of inherent conceptual weaknesses which have significant consequences for our understanding of the schizophrenic's experience of illness, both psychologically and socially. These weaknesses point to a fundamental need to reconsider the nature of the delusional experience. Although we cannot give a full explication of a theory of the delusional experience here, we will point out the conceptual weaknesses of the current definition and, in the next section, argue that a theory of agency makes sense of why delusion has been thought to be the basis of madness, as Jaspers said, "from time immemorial" and why schizophrenia has, therefore, been stigmatized. The tendency of the contemporary clinical approach to defining delusion is to emphasize the cognitive element while omitting or down-playing the affective and conative elements of the deluded person's experience. Delusions are typically defined, in this reductive fashion, as "(a) false beliefs, which, (b) are not susceptible to the ordinary processes of reasoning and appeal to evidence, and which (c) are culturally atypical... To be delusional, a belief must be held with complete convictionM (Fulford 1988,1994). This definition is representative of the Jasperian (1963) approach to defining symptoms of mental illness because it focuses on the form in which the illness is expressed rather than the subjective content of the person's illness experience. Yet, because delusions affect the whole of a person's self, they throw his entire global system of thinking, feeling and behaving out of balance. Even though in a clinical setting a patient's beliefs may be indicative of illness, delusions effect more than one's belief. Belief is simply one mental phenomenon among many which is affected by the illness. Since the cognitive, affective and conative elements of the deluded person's experience all play an important role in the person's intentions, which form the basis of his actions, it is difficult to see how the conventional clinical definition "cuts nature at the joints" (Hempel 1994). A careful analysis of the definition will reveal why it is both conceptually and epistemologically weak. Conceptually the conventional definition of delusion is weak first and foremost because of an inherent ambiguity in the criteria used to establish that someone's beliefs are false and that he is, therefore, delusional. Beliefs that are "based on incorrect inference about external reality" (DSM-III-R 1987), or are "not ordinarily accepted by other members of the person's culture" (DSM-III-R 1987), or are held onto "despite clear contradictory evidence" (DSM-IV 1994), do not necessary mean a person is delusional. For example, a person who believes he is HIV+ because of one sexual indiscretion is not necessarily delusional because his belief (despite evidence to the contrary) is not necessarily false (HIV has a long latency period and there is the possibility of getting a false negative), is certainly not unreasonable (safe sex literature always emphasizes that once is enough to become infected), and clearly is not culturally atypical (the prevalence of HIV infection around the world is staggering). For this reason, this definition makes it difficult to differentiate between someone who is delusional and someone who is merely mistaken. Complicating this picture further is the fact that some delusions are not beliefs at all but are value judgments (Fulford 1991) and, hence, are neither true nor false. A person who says, for example, that she is a bad person because Jesus does not love her (DSM-IV Video Case Studies 1994) is expressing a value judgment which a psychiatrist, short of intense persuasion, is hard pressed to prove false (Spitzer 1990). Such a person may be ill but, because she expresses her delusion as a value judgment rather tten a belief, she doesnt satisfy the clinical definition of delusion. Because of these conceptual ambiguities, the clinical concept is also weak epistemologically: These criteria are not signs of pathology per se. Since delusions have been recognized as an important feature of madness, one would think that their clinical definition would clearly demarcate their presence and cut nature at the joints. However, as Rosenhan and his colleagues showed (1973), it is quite difficult even for highly trained clinicians to know, based on purely cognitive criteria, if a patient is truly ill or just feigning psychosis. Hence, if we treat this definition operationally (as is the current goal with the DSM), we are simply not able, unambiguously, to plug in patients because many non-delusional people would "fit" the criteria while many delusional people would not.

﻿IV﻿. THE PROBLEM OF AGENCY AND SCHIZOPHRENIA When we consider the agency of the schizophrenic, the problem with the conventional definition of delusion is that it relies exclusively on what Aristotle (1987) called the formal cause as a way to explain delusion-influenced behavior. The conventional definition tells us only the pattern or style of the cognitive experience, but is insufficient, by itself, to explain agency and how a schizophrenic's actions go awry. Since mental states are characterized by Intentionality, by a directedness toward something (Brentano 1874), intentionality is a significant element to explain behavior (Searle 1984), but it is lacking in the conventional explanation of delusion. A desire, belief, wish, fear and so on is always a desire, belief, wish or fear about somethlng: it is always intentional. To explain the schizophrenic's agency, we need, therefore, to include a teleological explanation, what Aristotle called the final cause ("That, for the sake of which"), because a person's actions, whether he is delusional or not, are always directed toward some end. The problem with the deluded schizophrenic is that his actions felt because, for everyone, they are ununderstandable; that is to say, the end for the sake of which the deluded person acts (whether the action is based on a belief, desire, wish, hope, fear and so on) is not normal. This abnormality in a person's actions leads to social disapproval, to being treated as a fool, an outsider, or mad and, hence, leads to social stigma. The failure of a deluded person's actions, therefore, play a crucial role in determining that he is mad. Because a person with schizophrenia has a profound lack of insight about being ill, he is unaware of any change in himself and is unable to correctly judge the change in his mental state (Lewis 1934) and thus is incapable of recognizing that his intentions and actions are affected by his illness. This lack of insight is significant because It means someone other than the patient himself has to recognize his irrationality, his madness. One indication that is recognized easily by family, friends and others is the abnormality of the person's actions. When a schizophrenic acts, his actions are irrational and ununderstandable; this irrationality and ununderstandableness contributes to the stigma associated with this illness precisely because, as Jaspers recognized, "we do not value the ununderstandable" (310). While there is a danger in relying on social criteria for determining who is mentally illness (Lewis 1953) because it can lead to abuse (Fulford et al. 1993), social awareness of a person's madness (as exhibited in his actions and reasons for acting), nevertheless, precedes any clinical assessment of the illness and has always done so since time immemorial. That a schizophrenic's actions lead to stigma can be seen in the case of Japan where there appear to be two types of inter-personal behavior exhibited by schizophrenics. Both of these forms of behavior deviate from the normal standard and cause suffering not only to the patient but also to the patient's family. In one instance the person acts compulsively and is very direct, even confrontational by Japanese standards, in dealing with people. In the other case, the person withdraws from all social interaction and becomes nearly catatonic. Since the standard behavioral norm in Japan is one in which there is great restrain in social settings (Doi 1973; Lebra 1976), any excessively outgoing behavior, deemed inappropriate for the context, will be perceived as threatening. At the same time, any behavior seen as excessively restrained will also be perceived negatively. In Japan one must be aware of the appropriate social behavior for the context because it will dictate how one should act. The overly outgoing schizophrenics seem totally oblivious of these interactive norms and cause their families to experience shame because their loved one seems to lack control and seems to lack an understanding of the unwritten rules of how to behave publicly. Likewise, the overly quiet and reserved schizophrenic seems incapable of having any kind of interaction approximating the norm, regardless of the context. This type of behavior is likely to produce feelings of guilt in family members because they may feel that they have somehow caused their relative to behave in this unresponsive way. These inter-personal behavioral deviations are problematic for family, friends and others because they just don’t know how to deal with the abnormal behavior. Once we begin to see that it is through a failure to function in a social context that people might single a schizophrenic out for ridicule (or worse), the psychotic person's actions are easily recognized as one of the causes of the social stigma associated with this illness. Because a deluded person's actions deviate from cultural norms, and because his reasons for acting defy understanding, he becomes a problem for both his family and society. Since in Japan families take on a greater burden in the care of ili family members, it is likely that deviations from the norma! behavior patterns are a source of feelings of both shame and guilt. The conventional definition of delusion, therefore, does not capture the depth of the delusional experience because it does not consider the profound failure of the person's practical reasoning ability, an ability employing all the elements (cognitive, affective and conative) of the person's global sense of self defining Nm as an agent in society. It is only after the deluded person's behavior deviates from the social norm that it is deemed necessary to bring him under the gaze of medical scrutiny.V. THE USE OF BIOCHEMISTRY IN THE TREATMENT OF SCHIZOPHRENIA Biochemistry has had a major impact on removing some of the stigma associated with psychosis in the United States. While anti-psychotic drugs are used frequently in Japan to treat people with various kinds of psychotic disorders, it hasn't had as big a social impact as in the United States in removing the stigmas associated with these illnesses. Yet, with the greater availability of atypical anti-psychotic drugs, there is reason to believe that one day the social stigma associated with schizophrenia here will lessen. To achieve this end, however, requires greater public education about the nature of schizophrenia and its treatment so that both patients and families understand and can effectively deal with the social manifestation of the illness. Since the Japanese conceive of the self as a harmonious, simple whole, understanding the biochemical aspect of schizophrenia may help to remove some of the stigma associated with this illness. Once the Japanese understand that this illness is the result of a biochemical imbalance (rather than a fragmenting of the soul), they might more readily accept the illness like any other. They would then be more receptive to drug treatments because they would realize that the goal of using the drugs is to put the self back into balance. The idea of living a balanced life is one which is culturally very appealing. Because the Japanese tend view the mind and body as indivisible, many Japanese believe that illness is the result of a lack of harmony, or balance, in this whole. Hence, once a person's physical order is restored, the mind too will be restored, and the self will be balanced (Lock 1987). So, framing the illness in this manner could help to overcome many of the negative feelings people have about this illness. There are currently many anti-psychotic drugs used to treat schizophrenia in Japan. The most widely prescribed drugs are haloperidol, chlorpromazine and levomepromazine. In addition to these three drugs, sulpiride is also used to treat schizophrenia in Japan, although it is mostly used as an adjunctive drug. As in the West, the drawback with using these drugs to treat schizophrenia is that they can produce extra-pyramidal symptoms in patients, such as parkinsonism, dystonia, and akathisia. New atypical anti-psychotic drugs, like olanzapine, clozapjne and risperidone, are showing promise in clinical trials in the West because they seem to help schizophrenic patients previously resistant to drug therapy and because they also seem to have fewer side-effects than the typical anti-psychotic drugs. Risperidone is the only atypical anti-psychotic drug currently available for prescription in Japan. It appears to be as effective as the traditional anti-psychotic drugs for treating schizophrenia and, importantly, has fewer of the extra-pyramidal side-effects. Although olanzapine is not currently available in Japan, it should appear in the market in a couple of years. Clozapine, however, is not undergoing any further clinical trials in Japan due to the severe side-effects linked to its use New psychiatric drugs have a long wait before they can become available for clinical use in Japan. The reason for the wait has to do with the long, rigorous clinical trials that new drugs are required to go through in order to get governmental approval. Normally this approval process takes ten years. Even if the clinical trial of new drugs is done in the West, the trial studies must be repeated, by law, in Japan to prove effectiveness with a Japanese population. The reason the trials must be repeated is because it is hypothesized that the Japanese are biologically or genetically different from Westerners; therefore, the thinking is, it is better to err on the side of caution than to rush into using a drug that may not be effective with the targeted population. While the increased use of anti-psychotic drugs can help ameliorate the detrimental consequences of schizophrenia, lessening the stigmas associated with this illness will also require increased public education about the nature of the disorder and its treatment. One way to educate the public is for psychiatrists to meet with patients and their families in public health centers to inform them about the nature of the illness and the best methods currently available for treatment. This would give them an opportunity to hear about old and new drug treatments, to discuss their effectiveness, and to develop strategies for drug management as well as learn about the possible side-effects of their use. These public forums would also give family members of schizophrenics an opportunity to meet and discuss with each other how they cope with their ill family member. Even though a more integrated approach to treating this illness is a long term goal, such a goal is a worthy one for it would probably lead to a lessening of the social stigmas associated with schizophrenia in Japan.

VI. CONCLUSION Schizophrenia has been a much stigmatized illness is both the East and West. We have attempted to point to some of the possible reasons for this stigmatization. We feel that the pessimistic Kraepelinian idea about this disorder has had a lasting effect on popular consciousness about this disorder and that there continues to be residual effects from this conception in Japan. We also looked at how the Japanese term for schizophrenia "seishin-bunretsu-byou" probably contributes to the stigma because of the unintended consequences of the pejorative connotations of the Kanji used to translate the Western diagnostic term. Changing this term to a less-stigmatized one would probably benefit both patients and their families. We then offered a critique of the conventional definition of delusion pointing out a number of its conceptual difficulties. These weaknesses, we believe, are the result of a fundamental misunderstanding of the degree to which the delusional experience affects a person's global sense of self. Moreover, we argued that a fuller account of the deluded person's experience, particularly as an agent, offers fertile ground for reassessing not only how delusion is experienced by a schizophrenic but also for understanding one of the fundamental reasons schizophrenia has been a stigmatized illness. While we considered the behavior of schizophrenics in Japan to show how deviant delusion-based behavior leads to problems socially, we believe our analysis has implications for other societies as well. Finally, we discussed the role of biochemistry in the treatment of schizophrenia in Japan. We argued that a better public understanding of the biochemical nature of schizophrenia would enable the Japanese, for cultural reasons, to accept this illness like any other and would help to remove much of the stigma now associated with this illness in Japan.